Large rhabdomyosarcoma arising from the bladder in a 5-year-old girl who required open oophorectomy during tumor debulking procedure
The details matter when removing an ovary for fertility preservation, even though the procedure itself is relatively straightforward. The laparoscopic approach typically involves a 10 mm umbilical port to accommodate the endoscopic retrieval bag, which facilitates quick removal of the ovary from the patient’s body once the final ovarian arterial blood supply has been divided. Two additional 5 mm ports are needed for the dissection, which most often include left lower quadrant and suprapubic locations, for removal of the right ovary. This orientation is the same as that typically used for laparoscopic appendectomy, which is familiar to pediatric surgeons . The procedure begins with clear visualization of the uterus and both ovaries. This requires careful lifting of the fallopian tubes to view the entire ovary for any cysts or masses (Fig. 16.2). If both ovaries are normal, then dissection of the right ovary typically ensues, due to the laparoscopic orientation as described. If the left ovary is appropriate for removal, then the suprapubic port is eliminated in favor of a right mid-abdominal 5 mm trocar. At times, both 5 mm ports are positioned in the left or right abdomen (opposite from the ovary), particularly in very young patients (Fig. 16.3).
Laparoscopic view of both ovaries and uterus in a 7-year-old pediatric girl
Laparoscopic trocars for oophorectomy, in infant, pre-adolescent and adolescent girls. The monitor is located at the foot of the bed
In infants and pre-adolescent girls, the ligament of the ovary is long, the mesovarium is typically narrow, and the fallopian tube is located very close to the ovary, all of which increase the possibility of burn damage if the mesovarium is divided (Figs. 16.4 and 16.5). In these youngest girls, the mesovarium of the broad ligament between the ovary and the fallopian tube is grasped, and the fallopian tube is divided using the harmonic scalpel, at the isthmus, the location where it joins the uterus . Our team prefers salpingo-oophorectomy in very young girls, since the excision of the ovary alone often requires handling the ovary or using the harmonic scalpel too close to the ovarian capsule, resulting in 2–3 mm of tissue burn damage that is visible microscopically. In peri-pubertal girls and in teenagers, the mesovarium may be wide enough to provide a safe plane of dissection between the ovary and fallopian tube, without need for concomitant salpingectomy (Fig. 16.6). The goal is complete dissection with no-touch technique of the ovarian capsule. Dividing the fallopian tube and working from a medial to lateral orientation, the broad ligament is divided (Fig. 16.7). The ovarian artery with the suspensory ligament of the ovary is divided last, which preserves the main arterial blood supply to the ovary during the entire dissection and until the last possible moment (Figs. 16.8 and 16.9). The ovary is then quickly placed in an endoscopic retrieval bag and removed through the umbilical incision. The operating room team is verbally coached that the blood supply will be divided so that the team is ready. A 5 mm piece of the ovary is sharply removed and then submitted to the anatomic pathology lab as a routine specimen. The ovary is then placed into the cryopreservation media as quickly as possible after division of the ovarian artery. Our goal is for the ovary to be placed in the cryopreservation media in less than 2 min after the severing of the ovarian arterial supply, which guarantees the healthiest follicles possible.